CommercialCoverageHigh impact
Medical Policy and Coding Updates - April 2020
Premera Blue Cross·WA · Orthopedics, Oncology, Hematology +4 more·Medical Policy
Effective date
Apr 1, 2020
We identified it
Jun 18, 2026
Summary
Premera Blue Cross implemented comprehensive policy updates affecting multiple specialties with various effective dates from April 2020 through July 2020. Key changes include removal of site-of-service restrictions for orthopedic procedures (knee surgeries will use InterQual criteria), new drug coverage criteria for oncology and specialty medications, biosimilar preferences for cancer treatments, and updated medical necessity criteria for various therapies.
Action Required
Immediately: Review all policy updates as multiple effective dates have passed. Update prior authorization workflows for knee procedures (arthroplasty and arthroscopy) to use InterQual criteria instead of site-of-service requirements. Update drug formulary preferences to prioritize new first-line biosimilars including Trazimera for HER2-positive cancers, Ruxience for lymphoma treatments, and Zirabev for oncology. Verify coverage criteria for newly added medications including Reblozyl, Padcev, Brukinsa, and others. Train clinical staff on updated age criteria for Nucala (now age 6+ for eosinophilic asthma). Note: These are historical changes that should already be implemented.